A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?
Inform the client that the nurse will get reprimanded for not administering the medication
Document the client’s refusal on the medication administration record
Ask the client the reason for refusing the medication
Inform the client that refusal is not permitted and it is required that the client take the medication
The Correct Answer is C
Choice A reason: Informing the client about potential nurse reprimands is coercive and inappropriate, as it prioritizes the nurse’s interests over patient autonomy. This approach fails to explore the client’s reasons for refusal, which may involve side effects or mistrust, and does not support therapeutic communication or ethical care.
Choice B reason: Documenting refusal is necessary but not the first action. Exploring the reason for refusal allows the nurse to address concerns, potentially resolving issues like misunderstanding or side effects. Documentation follows after attempts to understand and educate, ensuring a therapeutic approach before recording the refusal.
Choice C reason: Asking the reason for refusal respects autonomy and initiates therapeutic communication. It identifies barriers like side effect fears or lack of understanding, enabling education or alternative solutions. This approach aligns with patient-centered care, addressing underlying issues to promote adherence while respecting the client’s rights.
Choice D reason: Stating that refusal is not permitted is coercive and violates autonomy. Clients have the right to refuse medication unless under involuntary treatment orders. This approach damages trust, escalates resistance, and contradicts ethical principles, making it an inappropriate initial response to medication refusal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Stating intent to harm self and others meets criteria for involuntary hospitalization (e.g., 302 commitment), as it indicates imminent danger. Mental health laws prioritize safety, requiring inpatient evaluation to prevent suicide or violence, making this client eligible for involuntary admission to stabilize their condition.
Choice B reason: Refusing a diabetic diet is nonadherence but does not meet criteria for involuntary mental health hospitalization, which requires mental health-related danger to self or others. This behavior may warrant medical intervention, but it lacks the psychiatric urgency needed for involuntary admission.
Choice C reason: Uncontrolled rage with assaultive behavior indicates imminent danger to others, meeting criteria for involuntary hospitalization. Mental health laws allow commitment to protect others and stabilize the client, as assault reflects a severe mental health crisis requiring inpatient intervention to prevent further harm.
Choice D reason: Poor hygiene does not constitute imminent danger to self or others, a requirement for involuntary hospitalization. While it may indicate mental health issues, it lacks the acute risk needed for commitment, making outpatient evaluation or support more appropriate than involuntary admission.
Correct Answer is A
Explanation
Choice A reason: This response reinforces professional boundaries while therapeutically redirecting the client to explore external social support, addressing potential dependency. It validates the client’s feelings without personalizing the relationship, promoting healthy coping and social integration, which are critical for mental health recovery and maintaining therapeutic integrity.
Choice B reason: Bluntly denying friendship dismisses the client’s feelings, potentially damaging trust and therapeutic rapport. This approach risks alienating the client, who may feel rejected, hindering open communication and progress in addressing underlying emotional needs, making it non-therapeutic in a mental health context.
Choice C reason: Suggesting other friends without exploration dismisses the client’s expressed feelings, potentially invalidating their emotional experience. The assumption about existing friends may not apply, and the response lacks therapeutic engagement, failing to address the client’s dependency or need for social connection, making it less effective.
Choice D reason: Affirming the client’s view of friendship blurs professional boundaries, fostering dependency and compromising therapeutic objectivity. While validating feelings is important, reinforcing a personal connection risks hindering the client’s ability to develop external support systems, making this response non-therapeutic for mental health progress.
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